Provider Demographics
NPI:1215017058
Name:KIM, SUK GOO (PHARMACIST)
Entity Type:Individual
Prefix:MR
First Name:SUK
Middle Name:GOO
Last Name:KIM
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10631 LOST TRAIL AVE
Mailing Address - Street 2:
Mailing Address - City:SHADOW HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91040-1272
Mailing Address - Country:US
Mailing Address - Phone:818-353-9033
Mailing Address - Fax:
Practice Address - Street 1:11301 WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90073-1003
Practice Address - Country:US
Practice Address - Phone:310-478-3711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33405183500000X
NV07881183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist